Failure to Provide Food at Resident-Requested Temperature
Penalty
Summary
A deficiency was identified when a resident reported consistently receiving cold food, particularly at breakfast, and stated that requests to staff, especially Certified Nursing Assistants (CNAs), to reheat the food were often met with responses that they were too busy or that the microwave was too far away. The resident, who is cognitively intact and independent in eating, indicated that this issue had been ongoing for months and that previous complaints to kitchen staff had not resulted in any changes. During observation, the resident was found eating in his room and reiterated his dissatisfaction with the temperature of the food. Another resident also reported that vegetables served at lunch were cold and unappetizing, and that breakfast was lukewarm. This resident expressed reluctance to request reheating, believing that staff would not comply. Observations confirmed that the food on the breakfast tray was not at an appropriate temperature. Interviews with staff revealed inconsistent responses: one CNA stated that if a resident requested reheating, the nurse would be notified and the food would be reheated in the pantry, while another CNA recalled having reheated food for the resident in the past, particularly when the resident missed meal service due to sleeping or being out for appointments. Other staff, including a Registered Nurse and the Social Services Director, reported no recollection of complaints from the resident regarding cold food. Review of facility policy indicated that meals should be nourishing, palatable, and considerate of resident preferences, but the observations and interviews demonstrated that the facility failed to consistently provide food at the temperature requested by the resident, thereby not supporting resident self-determination and choice as required.
Plan Of Correction
Corrective Action: Resident #104 and #04 were visited by the Director of Nursing and Food Service Director to determine if the resident's meal was served at an appropriate temperature and to their liking on 07/25/2025. Resident #104 and #04 stated that the meals are being served at the right temperature per their request. Staff A, B, and C were given a one-to-one education by the Director of Nursing regarding the importance of providing residents with meals at an appropriate heated temperature per their request. Identification of Residents: All residents in the facility have the potential to be affected by this alleged deficient practice. Systemic Changes: Ongoing in-services were initiated on 07/25/2025 by the Director of Nursing/designee to direct care staff regarding providing meals at appropriate temperatures per resident's request. The Interdisciplinary Team will conduct daily random rounds in resident rooms and dining rooms to ensure that residents are receiving their meals at an appropriate temperature per resident's preference. Meal temperatures will be discussed at the next Resident Council meeting per the resident's invitation, where the Dietician and/or designee will review and update any concerns with residents to ensure meals are served at an appropriate temperature per resident preference. Monitoring: The Director of Nursing and Food Service Director will conduct random food observation audits to check that food is served at temperatures per resident's preference. This audit will be conducted daily for 5 days, then weekly for eleven weeks to ensure that resident meals leave the dietary department at the correct temperature and are served to residents at an appropriate temperature per resident's preference. The results and findings from the audits will be reviewed and reported to the QAPI committee monthly for 3 months to ensure continued substantial compliance. Resident Council meeting per the resident's invitation, where the Dietician and/or designee will review and update any concerns with residents to ensure meals are served at an appropriate temperature per resident's preference. Monitoring: The Director of Nursing and Food Service Director will conduct random food observation audits to check that food is served at temperatures per resident's preference. This audit will be conducted daily for 5 days, then weekly for eleven weeks to ensure that resident meals leave the dietary department at the correct temperature and are served to residents at an appropriate temperature per resident's preference. The results and findings from the audits will be reviewed and reported to the QAPI committee monthly for 3 months to ensure continued substantial compliance.